Introduction
Ligation of internal iliac artery was first performed by Kelly for haemorrhage in
hysterectomy for carcinoma uterus without any major complication.(1)Severe post
partum haemorrhage(PPH) is one of the most common cause of morbidity and
mortality related to child birth. More than one third of maternal mortality has been
attributed to PPH .(2). Prompt identification of the cause and initiation of treatment
is the best way of effective management. Oxytocin , prostaglandins and even
hysterectomy have been performed .
We are reporting here our 8 years experience of 24 cases of severe PPH in whom
bilateral internal iliac artery ligation was performed and found as simple, effective
and life saving procedure where available manoeuvres failed.
Methods
This study was performed in Department of cardiothoracic and vascular surgery at
Maharana Bhupal Goverment Hospital, Ravindra Nath Tagore medical college
Udaipur (Rajasthan,India) between June 2003 to May 2012. During the study
period , there were 24 female patients who had torrential bleeding per vaginum due
to severe PPH in whom Cardio Thoracic Surgeon was called directly in operation
theatre for active intervention as last measure. Bilateral internal iliac artery ligation
was performed in all patients as an emergency procedure. The patients included in
this series were between age 20-40yrs. with mean age of 25.95yrs. All patients
except three were primi Para. All patients were resuscitated and standard treatment
was initiated. All patients whom we dealt were on continuous syntocinon infusion,
heavy inotropic support (Dopamine, Noradrenalin , adrenaline ) and two to four
units of blood transfusions were already been given before procedure.
Surgical Procedure
The abdomen was explored by extension of phennesteil incision vertically mid line
nearly up to umbilicus leading to “T” shape incision. This gives better visibility in
approaching common iliac artery bifurcation in presence of bulky uterus and
oedematous surrounding tissue. Packing and retraction of all surrounding bowel
loops were done. Retroperitoneal dissection was done, ureter was visualised and
retracted .The internal iliac artery was carefully dissected and separated from
fragile internal iliac vein. The artery was then lifted and looped around twice with
No.2 sutupack sutures. Double ligation of the artery was carried out without
division on both sides. Retro peritoneal layer was closed over vessel. No drain was
kept and abdomen closed in layers. Vaginal packing was done in all cases.
All patients were managed postoperatively in Obstetric ICU on ventilator,
continuous syntocinon infusion, heavy inotropic supports (Dopamine and
Noradrenalin) along with blood, FFP and Platelet transfusion , haemostatic agents
as per the need of patients .The inotropic drugs were tapered slowly between 48 to
72 hrs. All patients except one (who died after 12 hrs) were weaned off ventilator
between 24 – 48 hours. Vaginal packing was removed after 24hrs and changed
daily. Infection prophylaxis with broad spectrum antibiotics was given.
Results
During the 8-year study period June 2003 to May 2012 total number of deliveries
conducted in Department of Gynaecology and obstetrics were 141853. Total
numbers of maternal deaths during this period was 672 i.e. 473.72 per 100000
which has reduced to 350 in recent year. Out of 672 maternal deaths, 78 (11.61%)
deaths were due to severe PPH.
Cardiothoracic and vascular surgeon was called directly in emergency operation
theatre by obstetrician in 24cases of PPH, who were in severe shock due to
torrential bleeding per vaginum. All patients were under general anaesthesia on
controlled ventilation with heavy inotropic support. Crystalloid, colloid and blood
transfusion were given to maintain intravascular volume. All patients had received
syntocinon infusion and prostaglandins for uterine atony. In 8 cases (33.33%)
hysterectomy had already been performed by obstetrician for control of
haemorrhage but still patients were bleeding through vault. We performed bilateral
internal iliac artery ligation in all patients trans abdominally. All patients except
three were primi para. Most of the patients were between 20-30 years and were in
active phase of fertile period. In patients in which hysterectomy had been
performed were all between 20– 30 years except one who was 40 yrs. old. In all
24patients bleeding was due to uterine atony.
Out of 24 patients, 23 (95.83%) patients were successfully managed by bilateral
internal iliac artery ligation and discharged between 12- 18 days from Post natal
ward uneventfully. We had mortality of one (4.16%) patient due to irreversible
shock after12 hours.
One patient (4.16%) among survivors suffered from pulmonary embolism on 5th
post operative day. This patient was shifted in cardiology ICU and treated
successfully with Injection heparin infusion and non invasive CPAP.
Discussion
Udaipur lies in south zone of Rajasthan. Being surrounded by tribal zone, having
less awareness among people and poor transport facilities maternal mortality is
high as patients come in late stage with one or other complications. They come
with severe PPH ,when to save life of patient is really a difficult task. Bilateral
Internal iliac artery ligation in intractable PPH is an effective life saving method
and hysterectomy can often be avoided. Bilateral Internal iliac artery ligation has
been used in life threatening obstetrical, gynaecological or general surgery
haemorrhage. Prophylactic ligation to reduce blood loss has been used in radical
procedure as Wertheim hysterectomy, radical vulvectomy(3) and abdominoperineal
resection of carcinoma rectum.(4)Bilateral internal iliac artery ligation does not
hamper further reproductive function.(5) Bilateral internal iliac artery ligation does
not produce pelvic ischemia, it merely converts the high pressure arterial flow in
the pelvic arteries into a sluggish venous like flow allowing clotting and
haemostasis; and successful pregnancies have been reported after the procedure. (6,7)
Both absorbable and non-absorbable (silk) suture material have been used for this
surgery. Chromic catgut sutures allow recanalization of the artery whereas silk
does not. (6) In our series we have used no. 2 sutupack (non absorbable) and double
ligation was done in all cases to avoid any chance of recurrent bleeding which may
happen with absorbable sutures.
In our study 8 (33.33%) patients had undergone hysterectomy before we were
called for ligation. In 16 patients (66.67%) where we performed ligation none of
them required hysterectomy afterward and we feel bilateral ligation of internal iliac
artery could have saved the uterus in eight patients in whom hysterectomy was
performed earlier to control bleeding .
Our results are different from results of Sheikh & Fadul (8) and Evans (9) where 29%
and 57% patients respectively required hysterectomy after bilateral internal iliac
artery ligation. In our series none of the patient required hysterectomy after internal
iliac ligation. Nevertheless in 8(33.33%) patients hysterectomy had been done to
treat PPH but failed to control bleeding ,which was followed by internal iliac artery
ligation and was found effective. We feel generous use of haemostatic agents and
blood components like FFP and Platelets may further reduce the incidence of
hysterectomy. Further, we strongly recommend non absorbable braided thick
sutures should be used in all patients. Mukherjee et al(10) performed 36 cases of
internal iliac artery ligation with success rate of 83.3% in 6 yr. In our series the
success rate is 95.83% may be due to little small patients group (n=24) as
compared to Mukherjee series.
One patient in our series has developed pulmonary embolism. This was diagnosed
with symptom of sudden dyspnoea followed by urgent ECG, x- ray chest and 2D
Echo. Patient was managed with heparin infusion, non invasive CPAP. Patient
recovered after 3 days of ICCU management. This embolic episode could be due to
use of haemostatic agents, inotropic drugs, recumbence and multiple blood
transfusions. In our series all patients were managed in ICU with complete
monitoring of all parameters. All patients in our series were kept on ventilator and
inotropic supports postoperatively, from which patients were weaned off slowly.
This further emphasizes the importance of obstetric ICU management in post
operative period and early diagnosis and management of any complications which
might have saved 23 (95.83%) out of 24 patients.
Conclusion
We conclude that bilateral internal iliac artery ligation is a good option in
controlling severe PPH. It is a simple, rapid and effective life saving surgery. We
suggest that it should be considered as primary choice before proceeding for
hysterectomy to manage intractable PPH; thus saving fertility and menstrual
function. It is easy to perform with no added morbidity or mortality.
References
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